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Advanced Neurology Dysarthria with CSF overdrainage syndrome

and clipped just distal to the valve to stop CSF flow. On symptoms. Cerebellar lesions affect speech, leading to
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post-operative day 1, the patient showed complete resolution ataxic dysarthria, characterized by slow, monotonous,
of positional tremors and staccato speech, with significant irregular, and staccato speech, often slurred with a nasal
improvements in vision blurriness, dizziness, and headache. quality. 13-16
The staccato speech was completely resolved, with no In the presence of a VP shunt, overdrainage may lead
recurrence after 6 months. to ventricular collapse, catheter tip blockage, drainage
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3. Discussion loss, and increased pressure. LP shunt malfunction may
also result in overdrainage and spontaneous intracranial
The rapid improvement of dysfluent speech, headache, and hypotension. Programmable pressure valves, which adjust
dizziness supported the diagnosis of overdrainage syndrome. pressure based on an individual’s intracranial pressure and
Ataxic Dysarthria (staccato speech and stuttering) was body constitutions, are more effective than fixed valves
noted as a rare complication of this condition. in preventing overdrainage complications. Strategies to
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Overdrainage syndrome occurs when a shunt system reduce CSF flow and prevent siphoning include adjusting
excessively drains CSF, leading to spontaneous intracranial the pressure at which flow begins. The Medtronic Strata II
hypotension. This is typically manifested by postural valve can be externally reprogrammed to modify opening
headaches (holocranial, frontal, or occipital), nausea and pressure, whereas the NATUS H/V valve drains at high
vomiting when upright, neck pain, hearing disturbances, pressure when standing and low pressure when supine,
or tinnitus. Rarely, symptoms may include non-orthostatic addressing pressure differences due to gravity. Anti-siphon
headaches, gait disturbances, diplopia, upper back pain, devices can also be used to slow CSF drainage. Unfortunately,
dysarthria, and seizures as well as reduced consciousness, overdrainage syndrome lacks standardized clinical criteria. 12
cognitive issues, lower back pain, photophobia, or This patient’s history was complicated by EDS, which is
movement disorders. Symptoms can be acutely present associated with a higher incidence of Chiari malformation
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with an extradural hematoma. Intracranial hypotension type 1, IIH, and spontaneous intracranial hypotension
is best demonstrated through contrasted MRI, the most due to spinal CSF leaks. Increased IIH risk can result from
sensitive modality, showing diffuse venous engorgement jugular vein compression, drainage sinus obstruction,
and pachymeningeal enhancement in 73% (95% confidence or blood clot formation. The tendency for CSF leaks in
2
interval, 67 – 80%) of patients along with distention of the patients with EDS is linked to connective tissue weakness.
transverse sinus. The pituitary gland often shows marked Spontaneous leaks are most common in those with
enhancement, and there may be sagging of the brainstem hypermobility-type EDS. Patients with EDS are often
and cerebellum with a diminished prepontine cistern. Brain misdiagnosed; a survey of 505 individuals revealed an
MRI findings can be normal in about one-fifth of patients. average of 10 incorrect diagnoses. Anxiety, depression, and
2,11
Symptoms may also be absent for varying periods. migraines frequently contribute to these misdiagnoses.
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Current literature discusses the shunt siphoning of Another study found that 56% of 414 patients with EDS
CSF, which leads to overdrainage. When a patient moves received a misdiagnosis. Increased research and education
from a supine to an upright position, the pressure gradient about EDS are crucial, as first-line medical staff need to
between the ventricles and peritoneal cavity can create a be more familiar with its symptoms, comorbidities, and
negative hydrostatic effect, causing siphoning into the potential diagnoses. 19
abdomen. This can lead to ventricular emptying and 4. Conclusion
collapse, particularly in patients with post-hemorrhagic
hydrocephalus, aqueductal stenosis, or white matter injury. This rare case involves a patient with ataxic dysarthria,
Siphoning can result in postural headaches and subdural characterized by staccato speech and stuttering, due
hematomas. 12 to overdrainage syndrome. Prompt LP shunt revision
The patient’s neurological findings were characteristic resolved her symptoms. This case highlights the diagnostic
of cerebellar motor syndrome, featuring staccato challenges of overdrainage syndrome, especially in
speech, tremors, dysdiadochokinesia, and coordination patients with connective tissue disorders, where multiple
errors. In overdrainage syndrome, lower pressure in the symptoms can complicate diagnosis. Overdrainage and
subarachnoid space can create a vacuum effect, dragging underdrainage from LP shunt malfunction can cause
intracranial structures downward and causing cerebellar headaches, nausea, vomiting, visual changes, cognitive
sag. We believe that very low CSF pressure in the spinal issues, and neck pain.
canal when upright led to this sagging and mechanical Overdrainage syndrome is poorly understood, with
compression of the lower brainstem, resulting in cerebellar variable clinical manifestations and no standardized

Volume 4 Issue 1 (2025) 107 doi: 10.36922/an.4162